Mississippi Medicaid Bill Reverses a Trend of Limiting Care, With an Eye Toward Prevention

For 20 years, states hoping to rein in Medicaid spending have put limits on a person’s supply of prescription drugs—by capping the overall number of medications, the number of branded drugs, or some combination. Some states limited office visits, as well as prescriptions. Mississippi was among them.

Not anymore, if Republican Governor Phil Bryant signs a bill that represents a major shift in thinking for a state with historically poor rankings in everything from obesity to diabetes to preterm births, which also drew special attention under the legislation. The bill doesn’t just ease up on the caps, according to State Senator Brice Wiggins, R-Pascagoula, who chairs the Senate Medicaid Committee. It eliminates them, and redirects the agency’s energy toward preventive care with the goal of improving outcomes.

In an email to The American Journal of Managed Care^®, Wiggins said the change came about for 2 reasons: lawmakers listened to providers, and what Mississippi was doing wasn’t working.

Mississippi saw a surge in Medicaid enrollment after the Affordable Care Act took effect, and while enrollment is still higher than 2013 levels, it has dropped from its peak of 795,550 (Medicaid and CHIP) in April 2015. The most recent numbers on the state website show combined enrollment at 743,847. “Overall spending continued to go up, while enrollment was going down,” Wiggins said. The legislature reinstituted a Medical Care Advisory Committee, a statutory entity made up of providers, which recommended getting rid of the cap to focus on preventive care, Wiggins said.

The legislature allocated $917.5 million on Medicaid, an amount the federal government will likely match 3-1. Policy changes were included in a technical amendments bill, which accompanies the budget and sets out who qualifies for Medicaid, what the benefits are, and what rates providers are paid. The “tech bill” was highly controversial this year, with most of the debate over whether the legislature should force new bids on the state’s managed care contract; a plan led by hospitals sued after failing win part of the $3 billion business. The technical bill also addressed reimbursement rates, including potential increases for rural hospitals.

Studies have found that capping prescriptions is not a money-saver in the long run, and can cause some patients serious harm. A 2016 study by Lieberman et al, in BMC Health Services Research found the number states limiting Medicaid prescriptions rose from 12 in 2001 to 20 in 2010, including a sharp rise in states limiting brand prescriptions. That review found New Hampshire, which was 1 of the first states to experiment with prescription caps, achieved a $400,00 savings only to see it offset by a rise in nursing home admissions. California tried capping the annual cost of prescriptions for some beneficiaries, but found this group had higher rates of hospitalizations, emergency department visits, and deaths.

Even when prescription caps do not lead to a near-term episode, the research found that beneficiaries who must choose among prescriptions take those that alleviate symptoms—such as allergies, depression, or more serious psychiatric symptoms, and skip those for blood pressure or diabetes, which could lead to complications such as heart disease or a stroke. Medicaid enrollees may struggle to keep track of how many prescriptions they have each month, and these administrative burdens fall to physicians or pharmacists.

Medicaid prescription caps, and needs of the uninsured, helped create the “Walmart formulary,” the group of $4 generic drugs for common conditions. However, while $4 cash prescriptions have been a lifeline for many, Niteesh K. Choudhry, MD, PhD, and William H. Shrank, MD, MSHS, wrote in the New England Journal of Medicine that these prescriptions are often not recorded on electronic medical records, which could leave patients with an incomplete quality picture.

Critics of the technical amendments bill said it did not go far enough to bring transparency to the selection process for the managed care companies, and that the state still needs a better handle on whether managed care is delivering good quality. Wiggins said providers will continue to have a seat at the table.

“The committee has been empowered even further in the new bill,” he said. “It came down to, when you talked to providers, they said how ridiculous this cap was if you are trying to improve health.”